New York Times reporter Elisabeth Rosenthal, MD, visited Stanford this week for a Health Policy Forum, "Can we put a price on good health? Controlling the cost of health care," with Stanford health-policy researcher Doug Owens, MD.
Those who attended looking for answers, easy fixes, or a master villain were out of luck. Instead, attendees gained insight into a convoluted system that all agree is broken, yet no one has the total power, or know-how, to fix. Here's Rosenthal:
The issues and the problems are so diffuse... There's the tendency to be very reductionist - 'Oh, it's the hospital, it's the insurance companies, it's pharma'... We're all so codependent and it's all so intertwined.
Finances dictate what we do and the incentives are so powerful. The message to patients is that we're responsible too.
So that complimentary coffee you might get in a hospital lobby? Not actually free, Rosenthal said. She knows: While reporting for the well-known series "Paying Till It Hurts" she has talked to scores of patients and doctors and insurance representatives and policy-makers.
The main problems with the American health-care system are cost, quality and access, Owens said. The Affordable Care Act improved access, yet did little to lower costs or improve quality, he said.
And costs will continue to escalate if all the players remain most responsive to economic pressures, Rosenthal said. "Physicians feel like their income is being squeezed. Hospitals are better prepared to push back, and hospitals and physicians are looking to recoup some of that lost income in other ways. What's lost in that very real tug of war is that patients are held hostage in the middle. That's what's distressing," she said.
How does geography play into this, asked moderator Paul Costello, the medical school's chief communication officer, at one point. For colonoscopies (the procedure Rosenthal deemed her "favorite"), costs range from $1,908 in Baltimore, MD, to $8,577 a short train ride away in New York City. What gives?
"The games are slightly different in every zip code, but there are games in every zip code nonetheless," Rosenthal said.
Games? As in sport, a winner-take-all bout? "I probably should have used the word 'strategy,'" Rosenthal said. A business strategy, driven by the bottom line, profits, and the underlying fee-for-service system rather than a stable incentive to heal patients.
And patients are frustrated, scared and confused, she said:
They don't know what to do... There's no place to put that frustration. No politician is making a big deal of this. They are reluctant to say to their doctors, 'Look, I just can't afford this.' They are afraid to ask upfront about price, they think it's kind of rude.
Physicians, you've got to open up this discussion of price.
What if there were a price list posted at each hospital, at each doctor's office? Rosenthal said it would be a start, a nod toward transparency.
But that wouldn't work because pricing is so variable, Owens said. Physicians' groups and hospitals have contracts with many different insurance companies and other payers. "The physician may not know what something costs... The price is different from one person to the next," he said.
And sometimes, the unlucky get slammed with an unexpected $117,000 bill. Medical bills are a leading cause of personal bankruptcy, Owens pointed out.
Change is needed, but how can it start? The national effort, the Affordable Care Act, is considered a slur in some parts of the country. "Every part of our system is going to have to recalibrate... Every piece is going to have to think a little less about the financial incentives," Rosenthal said. Change can come at the state level, from hospitals, physicians groups — from everyone involved, she said.
"The first thing is to try eliminating things that don't help, then look at the value of the remaining things," Owens said. Large payers, such as Medicare, shouldn't just cut costs across the board, at the risk of harming good programs, he said.
Ultimately, it takes courage, an audience member said. Indeed, the speakers agreed. It takes the chutzpah to buck financial pressures, Rosenthal said.
The discussion continues online, at the New York Times' Paying Till It Hurts Facebook group - it's a meeting place of doctors, patients, scholars. Add your two cents (or, uh, two hundred).
Previously: Can sharing patient records among hospitals eliminate duplicate tests and cut costs?, Competition keeps health-care costs low, study finds and Does medical school debt cause students to choose more lucrative specialties?
Photo by David Goehring